NCG070130_Rescission Request_20210712

FOR AGENCY USE ONLY
NCG
Assigned to:
ARO FRO MRO WARO WIRO WSRO
RFO FIVER
DEN R-LAN.D QUAD 1TY
S TO R.M VVATE R PEERMITTING
Division of Energy, Mineral, and Land Resources Land Quality Section
National Pollutant Discharge Elimination System
Rescission Request Form
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
Directions: Print or type all entries on this application form. Send the original, signed application to: NCDEMLR
stormwater Program, 1612 Mail Service Center, Raleigh, NC 27699-1612. The submission of this form does not
guarantee recission of your NPDES stormwater permit. Prior to the recission of your NPDES stormwater permit, a
site inspection will be conducted.
1. Owner/Operator (to whom all permit correspondence will be mailed):
Name of legal organizational entity:
Legally responsible person as signed in Item (4) below:
CEMEX Construction Materials Atlantic LLC
Sigurd Bo - Director Environmental
Street address:
City:
State and zip code:
1501 Belvedere Road
West Palm Beach
FL 33406-1501
Telephone number:
Email address:
4072435316
[e-mail]
2. Industrial Facilitv (facility requesting rescission):
Facility name:
Hendersonville -Mud Creek
Street address:
2924 7th Avenue East
City:
State:
Zip Code: County:
Hendersonville
NC
28739 Henderson
Permit Number to which this request applies:
NCG070130
3. Reason for rescission Request
1F115 IS reyuIreu InIOFFTldU01I. JAL LdCrl bepdrdLe bRCeLb II 11Cl,CbJd1y.
El Facility is closed or closing. All industrial activities have ceased such that no discharges of stormwater are contaminated
by exposure to industrial activities or materials.
Date closed/closing: 2015
E3 Facility sold. ProP�r-F� -45 c '35- _ c'� Af / .3fwCC 13te—
Sold to: s4Is,na /Gvcstr �'�5l%�cs
On date: 2015
® Other (please explain): j Pr06?'e'7L,

4. Applicant Certification:
North Carolina General Statute 143-215.613 (i) provides that: Any person who knowingly makes any false statement,
representation, or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000). 1 hereby request exclusion from NPDES stormwater permitting.
Under penalty of law, I certify that:
0 I, as an authorized representative, hereby request recission of coverage under the NPDES stormwater Permit for the
subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief
such information is true, complete, and accurate.
Printed Name of Person Signing: Sigurd Bo
Title: Director Enui o7mental - Materials Division
of Applicant)
(Date Signed)
Mail the entire package to: DEMLR—Stormwater Program
Department of Environmental Quality
1612 Mail Service Center
Raleigh, NC 27699-1612
Page 2 of 2